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Antisocial personality disorder
Specialty	Psychiatry, psychology

Antisocial personality disorder (abbreviated APD or ASPD) is a psychiatric diagnosis in the DSM-IV-TR recognizable by the disordered individual's impulsive behavior, disregard for social norms, and indifference to the rights and feelings of others. The closely related concept psychopathy, which should not be confused with psychosis, covers a generally more severe personality disorder. The World Health Organization's ICD-10 diagnostic manual uses dissocial personality disorder instead. The term sociopathy, although having no current diagnostic criteria, is also sometimes used.

Explanation

Approximately 4% of men and 7% of women are thought to have some form of antisocial personality disorder according to the DSM-IV.

Central to understanding individuals diagnosed with antisocial personality disorder, or at least psychopathy, is that they appear to experience a limited range of human emotions. This can explain their lack of empathy for the suffering of others, since they cannot experience the emotion associated with either empathy or suffering. Risk-seeking behavior and substance abuse may be attempts to escape feeling empty or emotionally void. The rage exhibited by psychopaths and the anxiety associated with certain types of antisocial personality disorder may represent the limit of emotion experienced, or there may be physiological responses without analogy to emotion experienced by others.

According to the older theory of Freudian psychoanalysis, a person with antisocial personality disorder has a strong id and ego that overpowers the superego. The theory proposes that internalized morals of our unconscious mind are restricted from surfacing to the ego and consciousness. However, this explanation provides no insight into the cause or treatment of the problem.

Research has shown that individuals with antisocial personality disorder are indifferent to the possibility of physical pain or many punishments, and show no indications that they experience fear when so threatened. This may explain their apparent disregard for the consequences of their actions, and their aforementioned lack of empathy.

One approach to explaining antisocial personality disorder behaviors is put forth by sociobiology, a science that attempts to understand and explain a wide variety of human behavior based on evolutionary biology. One route to doing so is by exploring evolutionarily stable strategies; that is, attempting to discern whether the APD phenotype has evolved because it gains fitness specifically within, or alongside, the survival strategies of other humans exhibiting different, perhaps complementary behaviours, e.g. in a symbiotic or parasitic manner. For example, in one well-known 1995 paper by Linda Mealey, chronic antisocial/criminal behavior is explained as a combination of two such strategies.

Establishing the diagnosis

Antisocial personality disorder and the closely related construct of psychopathy can be assessed and diagnosed through clinical interview, self-rating personality surveys, and ratings from coworkers and family. For diagnosing psychopathy in forensic male populations, the Psychopathy Checklist-Revised (PCL-R) is considered definitive.

Diagnostic criteria (DSM-IV-TR)

The Diagnostic and Statistical Manual of Mental Disorders DSM-IV, a widely used manual for diagnosing mental and behavioral disorders, defines antisocial personality disorder as a pervasive pattern of disregard for and violation of the rights of others occurring since age 15, as indicated by three (or more) of the following:

1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
2. deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
3. impulsivity or failure to plan ahead
4. irritability and aggressiveness, as indicated by repeated fights or assaults (both physically or mentally)
5. reckless disregard for safety of self or others
6. consistent irresponsibility, as indicated by repeated failure to sustain steady work or honor financial obligations
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

The manual lists the following additional necessary criteria:

• The individual is at least 18 years of age.
• There is evidence of conduct disorder with onset before age 15 years.
• The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Mnemonic

A mnemonic that can be used to remember the criteria for antisocial personality disorder is CORRUPT:

• C - cannot follow law
• O - obligations ignored
• R - remorselessness
• R - recklessness
• U - underhandedness
• P - planning deficit
• T - temper

Criticism of the DSM-IV criteria

The DSM-IV confound: some argue that an important distinction has been lost by including both sociopathy and psychopathy together under APD. As Hare et al write in their abstract, "The Axis II Work Group of the Task Force on DSM-IV has expressed concern that antisocial personality disorder (APD) criteria are too long and cumbersome and that they focus on antisocial behaviors rather than personality traits central to traditional conceptions", concluding, "... conceptual and empirical arguments exist for evaluating alternative approaches to the assessment of psychopathy ... our hope is that the information presented here will stimulate further research on the comparative validity of diagnostic criteria for psychopathy; although too late to influence DSM-IV."

Sex differences: APD is diagnosed much more frequently in men than in women. Some argue that this difference is partly due to problems with diagnostic criteria, and that the sex difference in antisocial behavior may not actually be as big as current prevalence rates suggest. Specifically, the criticism is with the focus on physical aggression in the DSM-IV diagnostic criteria, with no attention given to relational aggression, in which women are more likely to engage than physical aggression.

Diagnostic criteria (ICD-10)

Chapter V of the tenth revision of the International Classification of Diseases offers a set of criteria for diagnosing the related construct of dissocial personality disorder.

Dissocial Personality Disorder (F60.2), usually coming to attention because of a gross disparity between behavior and the prevailing social norms, and characterized by:

• callous unconcern for the feelings of others;
• gross and persistent attitude of irresponsibility and disregard for social norms, rules, and obligations;
• incapacity to maintain enduring relationships, though having no difficulty in establishing them;
• very low tolerance to frustration and a low threshold for discharge of aggression, including violence;
• incapacity to experience guilt or to profit from experience, particularly punishment;
• marked proneness to blame others, or to offer plausible rationalizations, for the behavior that has brought the patient into conflict with society.

There may also be persistent irritability as an associated feature. Conduct disorder during childhood and adolescence, though not invariably present, may further support the diagnosis.

Relationship with other mental disorders

Antisocial Personality Disorder is negatively correlated with all DSM-IV Axis I disorders except substance-abuse disorders. Antisocial Personality Disorder is most strongly correlated with Psychopathy as measured on the Psychopathy Checklist-Revised (PCL-R).

Potential warning signs

Though Antisocial personality disorder cannot be formally diagnosed before age 18, three warning signs, known as the MacDonald Triad, can be found in some children. These are, a longer-than-usual period of bedwetting, cruelty to animals, and pyromania.

Not all children who exhibit these signs grow up to develop antisocial personality disorder, but these signs are found in significantly higher proportions than in the general population. Generally two-out-of-three indicates a very strong tendency towards sociopathy.

A child who shows signs of antisocial personality disorder will be diagnosed as having either conduct disorder or oppositional defiant disorder. Not all of these children will grow up to develop antisocial personality disorder.

The MacDonald Triad does not apply to Antisocial Personality Disorder, but references the supposed likelihood of becoming a serial killer. Although many serial killers do have APD, it is not a prerequisite to becoming one. The validity of the MacDonald Triad is also heavily debated to this day.

References

1. Pinkofsky HB. Mnemonics for DSM-IV personality disorders. Psychiatr Serv. 1997 Sep;48(9):1197-8. PMID 9285984.
2. Personality Disorders. www.personalityresearch.org.. Accessed May 2 2006.
3. Hare, R.D., Hart, S.D., Harpur, T.J. Psychopathy and the DSM—IV Criteria for Antisocial Personality Disorder (pdf file)

External links

• National Personality Disorder website for England
• "Into the Abyss." Article on street crime referencing the roots and consequences of sociopathic behavior

• Personality disorders